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HomeMy WebLinkAbout15564 � � � _�� CITY OF DIAMOND BAht DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES .r�_ „ 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRES$ , ���'A�'��� BUII,DING PERMTT APPLICATION FIRMLY ' 0 ADDRfESS ��S �[3 ��'i����� DATE CATIO -C� � NUMBEW �-/� #/C � ISSUE TYPE OCC APN LO TRACT DATE CONST. GROUP p OWNER - o ADDRESS 2 � " A � l�.��+' ��� ZONING SETBACKS W CITY /� � ZIP I'7 S� TEL. `i�'�,f`C).i�c� FRONT RW ❑ � APPLICANT TEL. REAR � � SIDE/SIDE STREET RW ❑ CONTRACTOR � � � `v " SIDE= ❑ � ADDRES �"��'� . < t� O CITY ` ����- ZIP a�"ZtTEL. 4 Y: PROPOSEDUSE � � ^�..t`� �. � � ARCH/ENG! �- � �- ���- � DESIGNEa NO.DWEL: NO. NO. � � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VAIUATiON -Q 6WNER-SUlLDER DECIARATiON SFR/ADD/REM . � O -0 I HEREBY AFFIRM UNOER PENALTY OF PERJURY THAT I AA/EXEMPT FROM THE CONTRACTORS LI- .GfltBge/C8f�10l� � �-W CENSELtWFORTHEFOLLOWMGREASON(SEC.7037SBUSMESSAN�PROFESSIONSCAQEANYCITVOR : (/� � ;U: COUNTYWfi1CHPEWIRESAPERMITTOCONSTRIJCT,ALTEPIMPftOVE,OEMOLISH,ORREPAIRANVSTf7UP �: W p8[IO/DBCk - p ��- TUfiE,PRpR TO IT3 ISSUANCE.ALSO RE�UIflES THE APPLICANT FOR SUCM PERMI'TO FILE A SIGNED - W� STATEMENT THAT HE OR SHE IS IICENSED PUiiSUANT TO TNE PROYISIONS OF THE CONTPACTORS U- f '�S- CENSELAW(CHAPTER 9(COMMENCING WITHSECTION�aoo)OF DIVISION 3 OFTHE BUSINESS AND PRO- - � POOUSpB � 7S' FESSIDNSGODE)ORTHATHEORSHEISEXEFiPTTHEftEFflOMANDTHEBA515FOHTHEALLEGEOEXEMP- V. TIONMlYVqLA7lONOF5ECT1047037.58VANYAPPLICANTFORAPERMITSUBJECiSTHEAPPLICANTTO - Z RB-ROOf �_ ACML PENPLN�'NOT MORE THAN FNE Ht1NDRE0 DOILARS�ESao)) Q ._Q ❑I,ASOWNEROFTHEPROPERTY,OAMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, COfi1fI18fClal _:Z- WILL00 TNE WORK,AND TNE STRUCTURE IS NOT IMEN�ED OR OFFERED°OR SALE(SEC.7044.BU51- J � NESS AND PqOFESSiON6 CODE:THE CONTMCTOriS UCENSE LAW OOES NOTAPPLY TO AN OWNER OF :� ���- PROPERTYWF108UILDSORIMPROVE37HEREON,ANOWHOOOESSUCHWORKHIMSEIFORHERSEIFOR - m -� -1HHOUGHHISOflHEROWNEMPLOYEES.PflOVIOE6THAT5U(:F1IMPROVEMENTSARENOTINTENOEOOR __� _L�1__ ,OFFEREOiORSAIEIFFWWEVEi1,THE8UI:OWGORIMPROVEM'eNTI550LDWiTHINCNEYEpflOFCOMPLE-. _ �� TION,THE OWNEfl�BUILDER N7LL HAVE Tr!E BURDEN OF PqOVIN�THAT HE Ofl SHE�IO NOT 6UILA OR �z� IMPROVEPDFiTHEPURPO5EOF5A!E). - --W-_ ❑I,ASOLNJEHOFTHEPROPEHT/,AAAF.%CLUSIVFLYCO�RACTINGWITMLICENSEDWNTflACTOflS . .[[. TQ CONSTRUCTTHE P(10JECT�SEC.7aN,BUSINESS AND PFlOf-E5510N5 CODE:THE CONTRACTORS ll V81U8SIOf1 �S� � _ADJ.AREA :-W-� CERSEI�WDOESNOTAPPIVTOANOWNEROFAPROPEHTYWNOBUIIDSOAINPROVESTHEREON.0.N0 ;�' NAiOCONfMCTSFORSUCHDROJECTSWITHACOtJTRACTOR(S)LIrENSEDGUPSUAkTT07HE(�NTflAG QUANTITY DESCRIPTION FEE ..Y__ rans ucase uw.�. . ,2 -� __O.: ❑IAM EXEMPT UNDER SEC. _B.d P.C.FORTHIS REASON - �_ � �. � _LL' DATE OW4EF - U . W '_— _�. LICENSEDCONTRACTOASDECLARATION - �j I HEflEBYAFFlRM UNOEIi PENALTY OF PERJURV TNAT IAM LICENSEO 11NUER PROVISIONS OF CHAPTER � � �d;;. 9(COMMENCIkpWITMSECTlO�l70W)OF�IVISION30FTHE8USINESSAN�PROFESSIO45GCCE,At�D _ .Z �-X_- AiY LICENSE IS IN FULL WRCE PND EFFECF- - - - - - �m -- - - - -� tL � � .O; LICENSE CLASS �' UC.NO. :. � e..�' DATE��' -y GONTRACTOR `'r h. � � _�' - - WaRKERS'COMPENSATION DECt�FiAT{DN Y -� - - �- `:�',' � ¢ '' - i HEREBV AFFIHM UNDSR PENALTV OF OERIURY ONEOFThE KOILOWINO D�CLAAATI04S: `� v �: ¢ t ���_ IHAVEPNDWILLAtAMTpINACERTIFICATEO�CONSENTTOSELF�INSUREWRV+'ORKtHS' _ - -;�,_ GOMPENSATION,A9PROVIDEDBYSECT10N3�o00FTHELA60RCO0E,FORTHECERFOftMANCE j W - Of THE WORN FOR WHICH THIS PERMIT IS ISSUEO. -- � W i HAVE PM1 WILL MAINTAIN WORKEflS'COMPENSATION INSURANCE.AS REQUIRED BY SECTIDh •Q- 37o00FTHE IABOR CODE,FORTHE PERFORMANCE OF THE WORN FOR WH:CH THIS PERMIT IS - �� -0- ISSUED.MYWORKEAS'COMPEfiSATIONIN RANCECARRIERANDPOUCYhUM6ERARL: CONSTRUCTION � .� � -�y��.- caRaiEa - �i�/�/�/ ` PLAN REVIEW i ��-- PoucYNUMBER ELECTRIC 1 ¢ �' , �� -_0�, (hN55EctpNNE�MOTBEC�IEi@OFnEPEFLMi�wactJEt0.NAREo co)oR�Ess} PLUMBING - a-� '�� W_ - i'Z_ I CERiIFY TiAT IN TFiE PEFiFORMANCEOF THE WOFK FOR WHICH THIS PERMIT IS ISSl1ED.i MECHANICAL :�j-- SHALLNOTEMPLOYANYPEPSONINANYMANNERSOASTOBECOMESUBJECTTOTHE- / _-N. WOFKEFS'COMPENSATIONLAWSOFCALIfORNIA,ANDAGREETHATI�ISHOULUBECAME INSPECTIONFEE r x -7..n � Y� :�/ SU&IECTTOTHEWORKEFS'COMPENSATIONPROVISIONSOFSECTION37000FTHELAej]R E,.� j ` ��� i '.�: E, s�wirHcoMa�rmn+m �/p/qpv�ls s. ISSUANCE e . .�d'. OAlE: / �v APPLICANT. ���r�j�=------I`e� ��1'' - - -SMIP , x €�-Y� �r�".c3� �i �� -.W- ENERGY P/C . . . � `�.':"'�.� '�`PT ;.J_: WARNINO:PAIIUHETOSECUREWORKERS'COMPEYSATIONCOVERAGEISU� WGUL,ANO AIIBE ���a�eY��-3 �'-_`� � LL St/BJECTANEMPLOYEflTOCWMINALPENALTIESANOGIVILFINESUPTOONEHUNDREDTHOU5AN0 � ENERGYPERMIT - DOLURS(S10o,o00�.IN ADOITION TO TNE CAST OF CAMPENSATION.DAMAGES AS PROYIDE�FOfi IN . � J SECTION3]OBOFTHELABORCODL.�NTEFEST,ANDATTORNEV'SFEES. RETENTIONFEE: - �+ ,`Q� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � -��_ i HEREBY AFFIPM UNDER PENALNOF PEPJl1PV THAT THERE IS ACONSTRUCTION LEN�ING AGENCY _______ _ - � FOHTME PERFOH�tANCE OFTNE WORK FOR WHICHTHIS PERMIT IS ISSUED(SEC.3a9�,CN.C.). � W- � � LENOEP'S NAME - f— LENOEH'SADDRE55 __ - --W- ICERTIFVTHA7IHAVEREADTHiSAPPUCATIONANDSTATETHqTTHEABOYEINFORMATqNiSCOHREGT. �� TOTAL FEES ( -._� IAOREETOCOMPIYWITHALLCfTYANDCAl1NTVORDINANC'e5AND5TATFLAWSflELATINGTOBUILDINO _. CONSTRUCTION,AND NEREBYAUiHORIZE REPRESENTATNES OFTHIS CAUNTYTO ENTER UPON TNE Z: A80VE�MENTKKJED PROPERN FOR INSPECTION PUFiPO5E5. ` COMMENTS -- � k�'�� �- ������ �= � - m PERMInEEN��) � (� s � � _,I�`rYz'�'' �� ..�,�..� 7��! 6"J N SIGNATUREOFPEPMInEE ��ATE �- � RECPT.NO. 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